67 year old with sob and bilateral pedal edema

 31/03/22

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A 67 year old male presented with shortness of breath and bilateral pedal edema.

K.Lasya Mithra, 9th semester

Roll No: 50

I have been given this case to solve in an attempt to understand the topic of  " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

CASE:

A 67 year old male , farmer by occupation, came with chief complaints of

 Bilateral Pedal edema since 6 months 

Shortness of breath since 2months

Back pain since 2 months

History of present illness:

patient was apparently asymptomatic 2 years back then he developed shortness of breath on exertion, associated with dry cough for which he went to hospital, he took medication for shortness of breath.He used to take medication   (inhalers)whenever he had shortness of breath.

 

Bilateral pedal edema upto knees  since 6 months,which was insidious in onset and gradually progressive. It is pitting type.

He also complained of shortness of breath from 2 months  which was insidious in onset and gradually progressed from grade 2  to grade 3 (NYHA) which is  associated with PND and no history of orthopnea.

 Patient complain of low back ache since 2 months which was insidious in onset gradually progressive .There is no radiation of pain . Pain is not relieved on medication. Pain aggravated since 1 week  and was unable to sit or stand.

Past history:

He is a k/c/o COPD since 2 years and on medication.

No history of HTN, diabetes, epilepsy, TB

Personal history:

Appetite: Normal

Diet: Mixed

Sleep: adequate

Bowel and bladder: regular

Addictions: 

occasional alcoholic, last intake 6 months back

History of smoking from 26 years but stopped 14 years back

Family history:

No significant family history

GENERAL EXAMINATION:

Patient is conscious, cohorent,cooperative and well oriented to time, place and person.

He is obese with distended abdomen

Pallor- absent

Icterus- absent

Clubbing-absent

Lymphadenopathy- absent

Cyanosis- absent

Pedal edema - present (B/L grade 2)

VITALS: on 31.03.2022(12.00pm)

B.P:110/70 mmhg

P.R:116bpm

R.R: 14cpm

Temp:101 F

SPO2: 99%@15L O2

GRBS: 152mg/dl

SYSTEMIC EXAMINATION:

Respiratory system:

Inspection:

 No tracheal deviation 

Chest bilaterally symmetrical

Moving equally with respiration on both sides

Type of respiration: abdomino thoracic.

No dilated veins,pulsations,scars, sinuses.

No drooping of shoulder.

Palpation:

No tracheal deviation

Apex beat- 5th intercoastal space,medial to midclavicular line.

Vocal fremitus- normal on both sides

Measurements:

Anteroposterior diameter- 21cm

Transverse diameter-30cm 

Ratio: AP/T- 0.7

Chest expansion: 2.5 cm

Percussion: 

Equally resonant on both sides                  

(Examined areas - Supra clavicular ,Infra clavicular, Mammary, Axillary, Infra axillary, Supra scapular, Infra scapular, Inter scapular)

Auscultation:              Right                  Left

Supra clavicular:       NVBS                  NVBS

Infra clavicular:         NVBS                  NVBS

Mammary:                  NVBS                  NVBS              Axillary:                    NVBS                  NVBS

Infra axillary:            NVBS                   NVBS

Supra scapular:         NVBS                   NVBS

Infra scapular:          NVBS                   NVBS

Inter scapular:          NVBS                   NVBS

CARDIOVASCULAR SYSTEM:

Inspection:

Shape of chest- normal

No precordial bulge or pulsations 

JVP - not raised 

Palpation:

Apical impulse was felt at 5th intercoastal space 1 cm medial to mid clavicular line

On auscultation , S1 S2 heard  No murmurs .

PER ABDOMEN :

          soft , non tender

          Umbilicus - inverted

          All quadrants moving equally with Respiration 

          No scars , sinuses, engorged veins 

          No palpable spleen and liver

          Normal bowel sounds heard.

CENTRAL NERVOUS SYSTEM: 

All higher mental functions, motor system, sensory system and cranial nerves- intact.

                        RT         LFT

BICEPS-           1+      1+

TRICEPS-        1+      1+

SUPINATOR- 1+       1+

ANKLE  -        1+       1+

KNEE-             1+       1+

At present:

PROVISIONAL DIAGNOSIS:

 COPD WITH RIGHT HEART FAILURE WITH BACKACHE (under evaluation)

INVESTIGATIONS:

31.03.2022

30.03.2022

29.03.2022

28.03.2022

25.03.2022( ADMISSION)

TROPONIN-I - negative

Ph-7.4
Pco2- 43.3 
Po2-97.4
So2-95
Hco3-26.7
On 4 ltrs o2
Blood group-A positive 
RBS- 132 mg/dl
Blood urea- 50mg/dl

Hemogram:

Hb - 11 gm/dl
TLC - 12400
N/L/E/M-92/3/2/3
PCV-36.2.2
MCV-75.9.9
MCH-23.1
MCHC-30.4
RDW - CV-17.4
PLT- 2.30
NC/NC with neutrophilic leucocytosis


Serum creatinine- 0.9

LFT:

Tb - 1.71
Db- 0.50
SGOT(AST) - 41
SGPT(ALT) - 38
ALP-250
Tp-5.4
Albumin-2.98
A/G - 1.23

SERUM ELECTROLYTES:
Na+ - 141
K+ - 4.3
Cl - - 97

Phosphorous-3.6 mg/dl

Serum ca+2 - 9.2 mg/dl

ECG- on 25 .03. 22

Chest Xray:

25.03.2022

26/03/22

ORTHO REFERAL(28.03.2022)

Lateral view of abdominal X-ray:

Xray of abdomen and pelvis:-

X Ray of pelvis and hip joint:

2D ECHO:

USG:

At the time of admission:25.03.2022

At present: 31.03.2022

 DIAGNOSIS: 

COPD with RIGHT HEART FAILURE and OSTEOPOROTIC FRACTURE of lumbar spine(L2).

TREATMENT:  31.03.2022

Nebulisation with Dorolin, Butecort - 6th hourly
Inj Lasix 40mg IV BD (8am-4pm)
(Check B.P before giving lasix)
Tab Hydralazine 12.5mg PO/BD
Tab Ecosporin AV/75/20mgPO/OD
Tab Ultracet 1/2 tab QID
Intermittent CPAP for 4 hours (With gap of 2hrs during feeds)
Vitals monitoring every hourly
Inj Zolendronic acid 4mg IV STAT

TREATMENT UPDATES

27/3/22

S-C/o SOB
PEDAL EDEMA DECREASED

O-
O/E: No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy.

Vitals:
Temp:Afebrile
PR:96bpm
BP:110/70 mm of hg
RR-18
SPO2-99%@10L O2

CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard on left side and on right side wheeze and crepts are present .
P/A:SOFT,NON TENDER,BS+
CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL
REFLEXES-
                        RT. LFT
BICEPS-.        1+. 1+
TRICEPS-.      1+. 1+
SUPINATOR-  1+. 1+
ANKLE. -.        1+. 1+
KNEE-.             1+ 1+

PROVISIONAL DIAGNOSIS:- 

COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION

P-
1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY
2.INJ LASIX 40 MG IV/BD
  CHECK BP BEFORE GIVING LASIX
3.STRICT I/O CHARTING
4.VITALS MONITORING EVERY 4TH HOURLY
5.TAB DOLO -650 MG /PO/SOS
6.TAB HYDRALAZINE 12.5 MG PO/BD
7.TAB CARVEDILOL 3.125 MG PO
8.TAB ECOSPRIN -AV(75/20. MG) x PO/OD
9.INTERMITTENT CPAP 4TH HOURLY

28/3/22

S-C/o SOB
PEDAL EDEMA DECREASED

O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy.

Vitals:
Temp:Afebrile
PR:114bpm
BP:100/60 mm of hg
RR-22
SPO2-99%@10L O2

CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard on left side and on right side wheeze and crepts are present .
P/A:SOFT,NONTENDER,BS+
CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL
REFLEXES-
                        RT. LFT
BICEPS-.        1+. 1+
TRICEPS-.      1+. 1+
SUPINATOR-  1+. 1+
ANKLE. -.        1+. 1+
KNEE-.             1+ 1+

PROVISIONAL DIAGNOSIS:-

COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION

P-
1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY
2.INJ LASIX 40 MG IV/BD
  CHECK BP BEFORE GIVING LASIX
3.STRICT I/O CHARTING
4.VITALS MONITORING EVERY 4TH HOURLY
5.TAB DOLO -650 MG /PO/SOS
6.TAB HYDRALAZINE 12.5 MG PO/BD
7.TAB CARVEDILOL 3.125 MG PO
8.TAB ECOSPRIN -AV(75/20. MG) x PO/OD
9.INTERMITTENT CPAP 4TH HOURLY

29/3/22

S-C/o SOB
PEDAL EDEMA DECREASED

O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy.

Vitals:
Temp:Afebrile
PR:116bpm
BP:100/60 mm of hg
RR-18cpm
SPO2-99%@10L O2

CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard on left side and on right side wheeze and crepts are present .
P/A:SOFT,NONTENDER,BS+
CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL
REFLEXES-
                        RT. LFT
BICEPS-.        1+. 1+
TRICEPS-.      1+. 1+
SUPINATOR-  1+. 1+
ANKLE. -.        1+. 1+
KNEE-.             1+ 1+

PROVISIONAL DIAGNOSIS:

COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION

P-
1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY
2.INJ LASIX 40 MG IV/BD
  CHECK BP BEFORE GIVING LASIX
3.STRICT I/O CHARTING
4.VITALS MONITORING EVERY 4TH HOURLY
5.TAB DOLO -650 MG /PO/SOS
6.TAB HYDRALAZINE 12.5 MG PO/BD
7.TAB CARVEDILOL 3.125 MG PO
8.TAB ECOSPRIN -AV(75/20. MG) x PO/OD
9.INTERMITTENT CPAP 4TH HOURLY

30/3/22

S-C/o SOB
PEDAL EDEMA DECREASED
Back pain not decreased

 
O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy.

Vitals:
Temp:Afebrile
PR:102bpm
BP:100/70 mm of hg
RR-15cpm
SPO2-99%@10L O2

CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard on left side and on right side wheeze and crepts are present .
P/A:SOFT,NONTENDER,BS+
CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL
REFLEXES-
                        RT. LFT
BICEPS-.        1+. 1+
TRICEPS-.      1+. 1+
SUPINATOR-  1+. 1+
ANKLE. -.        1+. 1+
KNEE-.             1+ 1+

PROVISIONAL DIAGNOSIS:

COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION

P-
1.NEBULISATION WITH IPRAVENT AND BUDECORT-8th HOURLY
2.INJ LASIX 40 MG IV/BD
  CHECK BP BEFORE GIVING LASIX
3.STRICT I/O CHARTING
4.VITALS MONITORING EVERY 4TH HOURLY
5.TAB DOLO -650 MG /PO/SOS
6.TAB HYDRALAZINE 12.5 MG PO/BD
7.TAB CARVEDILOL 3.125 MG PO
8.TAB ECOSPRIN -AV(75/20. MG) x PO/OD
9.INTERMITTENT CPAP 4TH HOURLY

31-03-22

S-C/o SOB
PEDAL EDEMA DECREASED
Back pain not decreased

 
O-
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy.

Vitals:
Temp:Afebrile
PR:102bpm
BP:100/70 mm of hg
RR-15cpm
SPO2-99%@10L O2

CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard on left side and on right side wheeze and crepts are present .
P/A:SOFT,NONTENDER,BS+
CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL
REFLEXES-
                        RT. LFT
BICEPS-.        1+. 1+
TRICEPS-.      1+. 1+
SUPINATOR-  1+. 1+
ANKLE. -.        1+. 1+
KNEE-.             1+ 1+

PROVISIONAL DIAGNOSIS:

COPD WITH RT HEART FAILURE WITH SEVERE LOW BACKACHE UNDER EVALUATION

P:

Nebulisation with Dorolin, Butecort - 6th hourly
Inj Lasix 40mg IV BD (8am-4pm)
(Check B.P before giving lasix)
Tab Hydralazine 12.5mg PO/BD
Tab Ecosporin AV/75/20mgPO/OD
Tab Ultracet 1/2 tab QID
Intermittent CPAP for 4 hours (With gap of 2hrs during feeds)
Vitals monitoring every hourly
Inj Zolendronic acid 4mg IV STAT